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A few years ago, the U.S. Centers for Disease Control and Prevention (CDC) issued guidelines of transmission of HIV and hepatitis B in health care workers. Soon after, the Occupational Safety and Health Administration (OSHA) issued its blood-borne pathogens rules. These together have set the minimum standards for personal protection of health care workers that have evolved into "universal precautions." All bodily fluids are thought to be infectious and are treated as such.
Emergency medical workers have a higher likelihood of exposure to possibly infectious agents than most other health care professionals. Studies indicate that the rate of HIV infections in hospital emergency departments (EDs) is around 8 percent and increasing. The rate among urban trauma victims alone may be as high as 16 percent. The nature of many ambulance runs also tends to increase the risk of contact with pathogens. Profuse bleeding from injuries, multiple sticks for venous access and cramped working space all make it more likely that exposure to harmful or fatal diseases could occur.
"The nature of traumatic injuries and of the urgent, invasive procedures that unstable patients often require may confer greater risk in health care providers," said Seth Wright, M.D., of the Department of Emergency Medicine at the Vanderbilt University School of Medicine. "Emergency medical responders (EMRs) may be at even higher risk because of the high proportion of critically ill or traumatized patients who are transported by ambulance. The considerably more chaotic and adverse situations encountered in the field compared with those in EDs may further increase their risk of exposure."
Researchers from Vanderbilt looked at the level of compliance with CDC and employer policies on universal precautions in field situations. What they found was disturbing.
Two medical students observed EMRs from the Nashville, TN, Fire Department EMS (NFD-EMS) during a three-month period in 1993. All observations were during 12-hour shifts in ambulance with two EMRs, at least one being a paramedic. Observations were made on all shifts and all days of the week. The EMRs were blinded to the existence of the study. They were told the students were collecting data on violence in pre-hospital settings. Medical students often observe EMS operations in the city. Over the three-month period of the study, there were 297 runs.
The students documented handling of sharps and use of personal protective equipment (PPE) such as goggles, gloves and gowns. Procedures followed included IV-line placement, endotracheal intubation, large-wound management and other bodily fluid hazards. (It should be noted that observations were based on both NFD-EMS and CDC requirements. In many cases, the procedural requirements of the local provider were stricter than those of the CDC.) Under the rules, proper handling of sharps such as needles or IV catheters consisted of immediate disposal into an approved container without recapping, bending, breaking the needle or handing off to another person. Proper handling of sharps was noted in only 37 percent of the cases. Most often, the improper action was handing the sharp to another EMR for disposal.
"The improper disposal of sharps is a significant hazard for EMRs, especially in the chaotic environment of the ambulance when attending to a severely ill patient," Wright noted. "Most documented HIV seroconversions in health care workers without risk factors are due to needle sticks."
Of the personal protection devices, only gloves were worn with any regularity. Even here the percentage of use fluctuated from 100 percent during intubation to 86 percent when body fluid hazards such as feces, emesis or urine were present. Use of gowns, masks and goggles are required by local rules and CDC suggestions during large wound management. NFD-EMS procedures mandate their use during IV-line placement and intubation. These barriers were not used in a single large wound management run. They were used in only 8 percent of the line placements and 14 percent of time during intubations.
The researchers suggest several reasons why compliance with universal precautions is so sporadic. For instance, many EMRs may find the extra equipment too much trouble to put on for patients they deem a low risk. In other studies cited by the Vanderbilt group, interference with ability to complete procedures, lack of availability once the EMRs leave the ambulance, and the perception that use slowed down the provision of emergency care were all leading reasons. It should also be noted that patterns of PPE usage by hospital emergency room staffs are similar to those in the field.
Kurt Ullman, a Firehouse® contributing editor, is a registered nurse and regional chairman of the volunteer Indiana Arson and Crime Association.